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Hypertonic Saline Use in Acute Decompensated Heart Failure
Study Questions:
In a real-world population of hospitalized patients with diuretic-resistant, acute decompensated heart failure (ADHF), is treatment with hypertonic saline (HS) with high-dose loop diuretics (HDLD) safe and effective?
Methods:
This was a single-center, retrospective cohort study of patients admitted with ADHF from March 2013 to December 2017. Included were patients who received HS (150 ml of 3% NaCl over 30 minutes) with HDLD. Patients who received HS for other reasons were excluded. Treatments were guided by an institutional protocol, which included requirements for intensive/progressive care unit admission, central venous access in most cases, and serial assessments (clinical exams, laboratory tests, weight measurements, urine output). The primary aim was to compare the trajectory of clinical variables from the 72 hours before and after HS.
Results:
Forty patients over 50 hospitalizations received a total of 58 HS treatment courses. Overall, this was a sick (inotrope or vasopressor use at 64%; 30-day rate of death, hospice, or readmission at 47%) and diverse (left ventricular assist device use in 25%; left ventricular ejection fraction >40% in 35%) cohort of patients. Improvements were seen in serum sodium, chloride, and creatinine after HS administration (p < 0.001). Improvements were also noted in total urine output (p = 0.01), weight loss (p < 0.001), and diuretic efficiency (p < 0.01). Regarding safety, there were no significant changes in supplemental oxygen use (p = 0.19) and no overcorrection of serum sodium over 24 hours (median +1.5, maximum +7 mmol/L).
Conclusions:
In this cohort with diuretic-resistant ADHF, HS use was associated with improved renal function, weight loss, urine output, and diuretic responsiveness. There were no significant safety signals.
Perspective:
This analysis suggests a possible benefit with HS use and favorable safety profile. However, key limitations exist including the study design (retrospective, lack of comparator, small sample, selection bias) and lack of data regarding confounders (changes in other therapies like inotropes, fluid and sodium restrictions, invasive hemodynamics). Given this, it is unclear what the natural course of these patients would be without HS and if the changes seen can be solely attributed to its use. Also, the cost implications for the resources linked to administration of HS are unclear. Ultimately, this study is hypothesis-generating but does present very intriguing results that should be studied further.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support
Keywords: Body Weight, Creatinine, Diuretics, Geriatrics, Heart Failure, Heart-Assist Devices, Hospices, Patient Readmission, Saline Solution, Hypertonic, Sodium, Sodium Chloride, Sodium Potassium Chloride Symporter Inhibitors, Stroke Volume, Weight Loss
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